Changing Health Care Delivery
Rural America struggles to recruit and retain health care providers, its residents are isolated from services, and its older population may be unable to access services in order to live safely and independently. Due to the unique health care landscape—and geographical landscape—of rural America, state policymakers, stakeholders and providers often take innovative approaches to how health services are delivered. States are exploring ways to address health service gaps and provide necessary care for rural patients, including leveraging the role of non-physician providers, using telehealth services, and providing home and community-based services for older adults.
Rural areas are disproportionately affected by provider shortages and other barriers to health care access for patients. A 2016 HRSA report found that, without any substantive changes to the rural health delivery system, 37 states are projected to experience primary care physician shortages by 2025. Additionally, medical students are more likely to pursue medical specialties and work in urban or suburban areas. While rural areas continue to experience primary care physician shortages, demand for primary care services is growing, partly due to an aging population and higher rates of chronic diseases.
Many states are leveraging non-physician providers—such as nurse practitioners (NPs) and physician assistants (PAs)—to address primary care service gaps. Each year, approximately 16,000 NPs graduate from primary care programs compared to 5,000 graduating primary care physicians. NPs are also more likely to practice in medically underserved communities, such as rural areas. The number of PAs practicing in the primary care field is expected to increase 39%, from 33,000 to 46,000, by 2025. Additionally, 15% of PAs practice in rural or frontier counties and many PA programs in rural states have a higher percentage of rural-practicing PAs.
For NPs and PAs to meet the growing primary care needs of rural communities, many state legislators are evaluating laws and regulations defining the roles and responsibilities of these health care workers, also known as scope of practice (SOP) laws. A number of states have taken steps to increase the practice authority licensure for non-physician primary care providers, as well ensure non-physician providers are reimbursed the same rate as physicians when providing the same services. Proponents of these laws say non-physician providers can be trained quicker and less expensively than physicians without compromising quality. Others argue that physicians’ longer, more intensive training equips them to diagnose more accurately and treat patients more safely.
States are evaluating SOP policies not only to improve access to primary care services, but to bolster necessary behavioral health services. While the prevalence of certain mental health conditions and substance use disorders are greater in rural areas than in urban locations, there continue to be behavioral health provider shortages in rural communities. Many states have allowed NPs and PAs to prescribe buprenorphine-containing products, which are used to treat opioid dependency. States have also established different licensing and credentialing standards for licensed professional counselors and addiction counselors to meet the mental and behavioral health needs of rural Americans.
NCSL’s Scope of Practice Policy Website
NCSL’s Scope of Practice Policy website is designed to provide state leaders with resources about scope of practice (SOP) issues for several non-physician providers, including nurse practitioners and physician assistants as well as six other providers. The website features interactive policy maps, a legislative database and case studies in SOP policy. For instance, the website tracked over 400 bills in the 2015 to 2019 legislative sessions related to NP and PA scope of practice.
Designed by NCSL with support from the Health Resources and Services Administration (HRSA), this resource aims to provide policymakers with a tool to explore the range of SOP legislation introduced around the country. This easily accessible information helps state leaders as they consider ways to meet the health care needs of their constituents at the right place, right time and right cost. Learn more at ScopeofPracticePolicy.org.
Beyond SOP laws, states are also developing various recruitment and retention policies to bring primary cares providers—including physician and non-physician providers—to rural communities. These often include pathway programs and scholarship and loan repayment programs. Pathway programs aim to introduce students from backgrounds underrepresented in health professions to health care careers. Participating students may be more likely to practice in their communities, such as rural or other underserved areas.
Scholarship and loan forgiveness or repayment programs provide financial incentives for students to practice in HPSAs—including several medically underserved rural areas—often for a minimum of two years. States can establish state-run programs and/or seek federal dollars for loan forgiveness and scholarship programs. For example, 41 states, Washington, D.C., and the Mariana Islands (U.S. territory) receive federal cost-sharing grants through the State Loan Repayment Program. States can use these federal dollars to provide loan repayments to various primary care providers, including physicians, NPs and PAs.
States are increasingly relying on telehealth to increase access to care for rural patients. HRSA defines telehealth as “the use of electronic information and telecommunication technologies to support long-distance clinical health care, patient and professional health-related education, public health, and health administration.” For patients living in remote areas with few providers, health professionals can provide a broad range of services virtually, including primary care and care for mental health, substance use disorder or oral health. Telehealth can also support rural providers by facilitating continuing education and collaboration among health care providers.
States are assessing payment, licensure and practice standards policies to further enhance the reach and effectiveness of telehealth services. All states and Washington, D.C., provide some form of Medicaid reimbursement for telehealth services, though coverage varies state to state based on telehealth modality and the scope of services covered. Forty-two states and Washington, D.C., have state laws relating to private insurance reimbursement for telehealth services, which typically entails private insurers offering comparable or equivalent coverage and/or reimbursement for telehealth services as for in-person services.
Additionally, states are evaluating licensure standards for health care workers to increase the use of and access to telehealth. Because telehealth often crosses state borders, providers may be held to several state-specific licensure requirements. Thus, states are adopting temporary licenses, telehealth-specific licenses and/or licensure compacts to facilitate services across state lines.
Lastly, providers using telehealth technology may experience barriers due to state-specific practice standards. Standards of care—or what another similarly trained and equipped provider would do in a similar situation—apply to all health care services, delivered remotely or in person. Some states, however, are adopting standards specifically requiring that the applicable standards of care that apply to in-person care also apply to telehealth.
States are continuously evaluating different telehealth modalities to expand access to telehealth services. The three primary methods of telehealth are real-time communication, store-and-forward and remote patient monitoring. Mobile health is still an emerging modality.
- Real-time communication allows patients to connect synchronously with providers via video conference.
- Store-and-forward refers to transmission of data, images, sound or video from one care site to another for evaluation.
- Remote patient monitoring involves collecting a patient’s vital signs or other health data while the patient is at home or another site and transferring the data to a remote provider for monitoring and response as needed.
- Mobile health (mhealth) is an emerging field that includes health education, information or other services via a mobile device. Mhealth references are much less common in state policy, with Hawaii as the only state with mobile health defined in statute.
Sources: Health Resources and Services Administration, NCSL, 2015
Home and Community-Based Services
With an older and sicker population making up a large share of rural communities, ensuring access to high-quality long-term services and supports (LTSS) for seniors and people with disabilities is of high importance for rural America. LTSS includes a broad range of day-to-day assistance for individuals with chronic health conditions and significant health challenges affecting daily activities. LTSS is often delivered by nurses and direct care workers, and demand for these workers is anticipated to increase markedly in the coming years.
Medicaid is the nation’s largest payer for LTSS, and although older individuals and people with disabilities make up less than one-quarter of Medicaid beneficiaries, they account for almost two-thirds of Medicaid spending. These high costs are especially prevalent in rural areas where a larger share of residents, especially older residents, are covered through Medicaid. For example, studies of rural LTSS use found rural Medicaid beneficiaries were more likely to use nursing home services compared to their urban counterparts, often restricting consumer choice and driving up costs for state Medicaid programs.
States can leverage home and community-based services (HCBS) to shift away from institutionalized care and help older individuals “age in place.” HCBS refers to services provided in one’s own home or community rather than a health facility. Rural seniors and individuals can receive various types of health and social services through HCBS, including skilled nursing care, occupational and physical therapy, hospice care or everyday personal care. With 3 in 4 Americans preferring to remain in their homes while aging, HCBS not only meets patients’ preferences but also results in significant cost savings to state Medicaid budgets. The Medicaid and CHIP Payment and Access Commission found an increase in HCBS compared to institutional care for Medicaid beneficiaries due to concerns about the high costs of institutional care and overall patient preferences. Additionally, a 2013 AARP analysis of publicly funded HCBS programs found lower per-person costs for HCBS compared to institutionalized care and an overall slower growth in health care costs.
In order to improve access to HCBS, states may seek federal funds to help older individuals and those with disabilities transition from institutional care to home and community-based settings, evaluate HCBS benefits for state Medicaid programs and target specific populations requiring long-term care. For example, nearly all states and Washington, D.C., offer long-term care services through a Medicaid HCBS waiver, also known as a 1915(c) waiver. States can “waive” certain federal requirements for state Medicaid programs to better fit the local context and HCBS needs of their state. Through a Medicaid HCBS waiver, states can target a certain area with a greater need rather than the entire state, make Medicaid services available only to a particular group or population, and provide Medicaid services to individuals who would otherwise only receive Medicaid coverage in an institutionalized setting. Medicaid HCBS waiver programs vary greatly, reflecting the significant role legislators, government officials and other stakeholders play in shaping a state’s HCBS policies.
Additionally, several states are enacting policies to relieve the financial burden for family caregivers, who provide a large share of HCBS, often without compensation. Several states have enacted paid family leave laws, which allow family caregivers to receive employer benefits while caring for older family members. Furthermore, various states—including Arizona, Hawaii, Minnesota, Virginia and Washington—have established state-run programs that provide reimbursement and other financial assistance to family caregivers.
State Spotlight: Wisconsin
Wisconsin Family Care is a Medicaid long-term care program for eligible older adults and adults with physical, mental and intellectual disabilities. The program, which aims to provide support and services for individuals in their own homes whenever possible, has two major organizational components. The Aging and Disability Resource Centers (ADRCs) provide information on which long-term services are available for older adults and adults with disabilities in their local communities. Managed care organizations (MCOs) collaborate with ADRCs to ensure enrollees have a coordinated care team to provide services specific to an enrollee’s needs and preferences. Medicaid MCOs pay for HCBS through capitated payments, a per-patient monthly payment, to control costs and promote quality. Due to the program’s costs savings and positive clinical outcomes, the Wisconsin Legislature enacted legislation to expand the Family Care program statewide and eliminate all remaining waiting lists for HCBS.
Health Care Delivery Policy Options
- Assess and consider scope of practice, licensure and payment parity policies for the non-physician workforce.
- Establish and fund recruitment and retention programs for the rural health care workforce. Policymakers can do this by supporting new or expanded residency programs, trainings and rotation opportunities in rural health care facilities.
- Consider policy options expanding access to health services via telehealth, including payment and reimbursement, licensure standards and standards of care.
- Evaluate effective state policies for improving access to and the quality of HCBS for older rural residents, such as increasing HCBS benefits and supporting family caregivers.